The Future of Medicare Reimbursement Is Here

The Centers for Medicare and Medicaid Services (CMS) will start paying hospitals bonuses based upon performance, an adherence to quality measures, and on patient satisfaction.  These final Medicare rules were published last week. This Hospital Value-Based Purchasing Program is another step toward shifting the reimbursement infrastructure from the cost of services during a hospital stay to improvements in patient health and performance during a hospital stay.

Proponents of this idea — which was part of the Patient Protection and Affordable Care Act — contend it could help save money in the Medicare system as it improves patient care nationwide. “For the first time, hospitals are going to be paid for inpatient hospital quality, not just the quantity of the care they provide,” CMS administrator Donald Berwick, MD, told reporters on Friday morning.

The rule goes into effect in October 2012. In the program’s first year, hospitals will be entitled to share bonus money from an $850 million fund based upon their performance. For a complete list of the quality measures, visit here.  CMS will also evaluate patient satisfaction during hospital stays. Quality measures will weigh at 70% and patient satisfaction results at 30%.

In fiscal year 2013 (starting October 2012), hospitals will face a 1% reduction overall on Medicare payments under the Inpatient Prospective Payment System (IPPS) as these funds will be used to pay for the performance bonuses. By 2015, hospitals who continue to show poor performance ratings will not only be excluded from the bonus pool, they will also face additional cuts in reimbursement.

When asked if the rule would be unfair to hospitals with less money who might have greater challenges adhering to the quality measures and focusing on patient scores, Berwick stated: “We need all boats to rise on the rising tide of quality.”


A Possible Reprieve for Hospital Retrofitting Requirements

In February, Hospital Stay posted an overview on California’s seismic safety requirements for hospitals.  That article can be found HERE.  Recently Governor Brown signed SB 90 and AB 113, which in part provide hospitals with a possible seven year extension to comply with the State’s seismic safety requirements.

To qualify, there are some legislative events which must occur first on both a state and federal level. If and when that occurs the seismic extensions set forth in SB 90 last up to seven years, but no later than 2020.  For a hospital to obtain this optional extension, OSHPD must consider public safety when determining whether to grant an extension or length of an extension on a case-by-case basis using the following criteria:

  • Structural integrity of the building based on its HAZUS score. HAZUS is a nationally applicable standardized methodology that contains models for estimating potential losses from earthquakes, as well as other natural disasters.
  • Community access to health care if the hospital building is closed.
  • Financial capacity of hospitals to complete the construction project.

No later than March 31, 2012, hospitals that wish to apply for the extension must:

  • Submit a letter requesting an extension.
  • Specify what the project will be (rebuild, retrofit, other).
  • Specify the time necessary for the project.
  • Submit a schedule detailing the extension work.
  • Specify how the project will stay on track as proposed.

No later than September 30, 2012, a hospital must submit its HAZUS application No later than January 1, 2015, a hospital shall:

  • Submit plans and a schedule for the project identified.
  • Submit a financial report describing the ability to complete the project.

No later than July 1, 2018, a hospital must obtain a building permit for its project, thereby ensuring sufficient time to meet the statutory deadline.



Why Movie Stars Marry

A recent study published in the Journal of Human Capital examines movie star marriages in an attempt to identify why people often marry someone with a similar educational background. According to Gustaf Bruze, an economist at the Aarhus School of Business and Social Sciences in Denmark, the answer has less to do with financial or professional considerations, and that just because a couple attended the same school is not necessarily conclusive.

Bruze reviewed information about the top movie stars’ marriages, earnings, and education levels. The analysis showed that the level of formal education may have little to no correlation with success (either financial or the likelihood of winning an industry award).  Notwithstanding, movie stars who marry still tend to have similar educational backgrounds, even though it is unlikely a couple met in school or on a film set as a result of their their education level.

Bruze noted that the findings suggest education is not dependent upon financial or professional  connections. “What it says is that men and women have very strong preferences for nonfinancial partner traits correlated with education. And educational sorting would remain even if the tendency of men and women to work with colleagues of a similar educational background were to disappear or if the role of educational institutions as a meeting place for future husbands and wives were to disappear.”

A Punch Up At A Wedding

Lost Hospital — Ellis Island Hospital, New York Harbor0

Between 1892 and 1954, Ellis Island served as the only entry point into the United States for more than twelve million immigrants. A small island inside New York Harbor located just off the New Jersey coast and the nearby Statute of Liberty, Ellis Island grew over the years from its original 3.3 acres to 27.5 acres in size.

Before 1890, individual states regulated immigration. When the Federal government assumed this responsibility, it constructed and operated a new facility on Ellis Island, opening its doors on January 1, 1892.

For the most part, class and status dictated whether an immigrant was sent to Ellis Island. Travelling across the Atlantic Ocean (the only real viable option at the time), first and second-class passengers were only sent to Ellis Island if they were sick (or had legal issues).  Third class passengers, also known as “steerage”, would almost always be sent to Ellis Island by ferry or barge for a medical examination.

If one’s legal documents were in order and he or she appeared to be in good health, the time spent on Ellis Island would be brief.  Doctors conducted medical examinations by quickly scan all newcomers for obvious physical ailments (sometimes referred to as the “six second physical”).

Fearing danger to the public health, immigrants with contagious diseases were excluded from entry into the United States. As a result, a hospital was needed on Ellis Island to treat the immigrants and protect the public health, and it opened in 1902. The contagious disease hospital was built with 18 wards for specific diseases, and it also included a psychiatric hospital.  Eventually the hospital would grow to include 22 buildings on Ellis Island.

A report by Assistant Surgeon General H.D. Geddings in 1906 stated: “The hospital building is of modern construction, on the block plan, of brick and stone construction, architecturally very handsome, and three stories and an attic in height, with a basement.  The general plan of the building is a central portion for executive and administrative purposes, with wings containing large and small wards.”

The Ellis Island Hospital received heat, light and power from a plant on Ellis Island. The hospital’s kitchen prepared 2,000 meals each day for the immigrants and 300 employees. According to the Commissioner of Immigration, Federic C. Howe, in 1916 Ellis Island would accommodate “as many as 10,000 people temporarily or permanently.”

The Ellis Island Hospital handled all diseases, including measles, mumps, diphtheria, and whooping cough. The hospital also had its own state-of-the-art laboratory, critical at the time to identify cases such as pulmonary tuberculosis. Indeed, the hospital reported only one employee death due to infection with contagious disease (tuberculosis) while working with the immigrants.

According to Dr. Milton Foster in 1915, “The medical inspection of arriving immigrants is made chiefly for two purposes; first, to see that they are strong, well, and bright enough to be able to earn a living and get along in this country; and second, to ascertain that they do not have certain diseases which they might transmit to their new neighbors in America.” While it treated disease and the passing of 3,500 patients, Ellis Island Hospital also delivered 350 babies (receiving immediate citizenship at birth).

The hospital screened immigrants for mental illness as well, usually a process initiated with an “X” chalk marked on the jacket or dress of the immigrant.  According to Dr. Thomas Salmon in 1905: “Justice to the immigrant requires a carefully considered diagnosis; while on the other hand, the interests of this country demand an unremitting search for the insane persons among the hundreds of thousands of immigrants who present themselves annually at our ports of entry.”

Physicians from the U.S. Public Health Services were required to rotate through the hospital. The patient load on Ellis Island was challenging. According to Dr. Foster, the volume compared to that of the hospitals in both Boston and Washington, D.C.:

“Take any week in the year and imagine that, during this week, all the people who were sick and needed treatment in [Boston and Washington, D.C.] were to be sent to one hospital.  Assume, also, that this hospital was a real general hospital, in the fullest sense of the word, and that it accepted not only ordinary patients but also the insane and those suffering from contagious diseases. Let us also further suppose that all . . . were inspected and that all those who were suspected of having latent disorders, like tuberculosis or syphilis, were also sent to this hospital for examination and treatment. Grant all of these conditions and you will have a pretty fair idea of the total amount of work performed by the hospital at Ellis Island last year.”

Restrictions on immigration ultimately proved to be the end of Ellis Island Hospital. Additionally, physical screenings were conducted overseas before transatlantic voyage was permitted.

As the number of patients began to decrease, Ellis Island was used by other government agencies such as the FBI (using the island to deport possible foreign spies), the U.S. Army (during World War II for its disabled servicemen as well as German and Italian prisoners of war), and finally the U.S. Coast Guard. In fact, it was the U.S. Coast Guard that ultimately closed the facility in 1954.

Photographs from, and U.S. DHHS.


Exercising Restraint – The Role of the Neighborhood ER in Treating Mental Illness0

“How do you know I’m mad?” said Alice.  “You must be,” said the cat, “or you wouldn’t have come here.” –Lewis Carroll

The challenges facing the local Emergency Room are as varied and complex as the patients it serves.  From trauma surgery to heart attacks to poisoning and beyond, today’s ER must be prepared for just about any health related issue, ready to quickly and accurately diagnose and treat whatever comes through its doors.  Fortunately, the advent of superior diagnostic technology has made the path between illness and wellness increasingly more linear.  So is the case, at least, with matters of the body.

However, when a patient’s illness is mental in nature, the role of a hospital becomes much more complicated.  What happens when a mentally ill patient gets sick in the outside world and must seek help not in a psychiatric care facility, but the neighborhood Emergency Room?  Unlike a trauma or stroke victim, whose injuries typically present as physical, issues of mental health are much harder to pinpoint, diagnose and treat in a timely fashion, as it is primarily the patient’s judgment that falls under question. Proper medical treatment of a mentally unstable patient requires not just the delivery of emergency medicine, but an understanding of the decidedly nonlinear practices of psychiatric medicine as well.  If that was not enough, it also often involves the ability to navigate additional legal hurdles and a host of ever-evolving ethical considerations unique to the psychiatric patient.

Recent advances have attempted to ensure that acute care hospitals afford psychiatric patients the same caliber of service as those presenting with physical ailments, with some success.  Passed in 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) is a United States Act of Congress that requires every hospital to treat any patient with an emergency condition in such a way that, upon the patient’s release, no further deterioration of the condition is likely.  No hospital may release a patient with an emergency medical condition, physical or mental, without first determining that the patient has been stabilized.  For those who come to the ER with severe mental disabilities, this can create an unusual situation where understanding, patience, and compassion are of great importance.

Though these regulations mean well, the reality they impose often puts hospitals in an awkward position, stretching their already limited resources to include a patient body that brings with it an increased demand for high-level, time-consuming care.  Once admitted to the ER, psychiatric patients often have to wait hours or even days before they are issued a bed within the hospital.  To make matters worse, a disproportionate number of mental patients in the ER also abuse alcohol and / or drugs, making it impossible for doctors to accurately assess the extent of their health until detoxification has been established.  In the interim, beds, services, and staff that would otherwise be used for Emergency Room patients presenting with physical conditions become tied up in the often long wait that comes with getting mental patients situated and provided for prior to diagnosis.  In truth, when it comes to any underlying psychiatric disorder most ERs are only equipped to offer mental patients a hot meal, a place to sleep, and protection, not only from the dangers of living on the streets, but often from themselves.

Treating the mentally ill presents a host of challenges to any ER, and includes addressing methods of communication and adherence to proper modes of conduct.  Even with today’s psychiatric advances and new procedures for doctors to employ when treating the mentally disturbed, the concept of patient safety remains at the top of any hospital’s list of priorities.  The very nature of mental illness can force gray issues when it comes to the acceptability of certain of these methods, such as the use of physical restraints on patients. Psychiatric concerns are unique in that they may force a hospital into the unenviable position of having to choose between a patient’s basic right to freedom and the need to protect the patient from himself.

From the hospital’s perspective, the need to balance prevention of self-inflicted patient harm, as well as harm to other patients and hospital staff, with the above-referenced concerns justifies the use of restraint in certain situations.  While a doctor can never legally use restraint as a means to prevent a voluntary patient from leaving the hospital prior to assessment, since every medical patient has the initial right to leave against medical advice, such an alternative does unfortunately continue to serve a purpose when all other options have been exhausted.

Due to the extremity of such a step, the regulations governing how a hospital may restrain a patient who has been assessed as a danger to himself or others are complex.  Again, the safety and well-being of the patient must always be of primary concern.  Though the laws differ by state, most hospitals agree on a set group of principals by which to abide should this step become necessary:

  • Restraints will be used only for adequately justified situations that are medically necessary based on individually assessed patient needs and behavioral risk factors.
  • Restraints will never be used as a means of coercion, discipline, convenience or retaliation by staff.
  • Restraints will not be based solely on prior history of use or history of dangerous behavior.
  • Preventative or alternative strategies will be used to help staff focus on the patient’s well being and will be incorporated into the patient’s plan of care.
  • Medication used to control behavior will be identified on patient’s medical record and included in patient’s plan of care.
  • Informed consent will be obtained prior to administering any psychotherapeutic medication.
  • The patient’s dignity, rights and well-being will be preserved and physical needs will be met while protecting the patient’s health and safety.

These categorizations, while understandably vague at first glance, do provide a much needed structure on which Emergency Room physicians can rely when a patient presents with issues of mental instability and questionable judgment.  Unlike patients dealing with physical ailments, the mentally ill must be treated under their own subset of conditions, taking into consideration the hidden complexities of the human mind.  Though no doctor ever wants to supersede the rights of a patient, on occasion he or she must be both willing and able to step up and accept responsibility for the well-being of another when that person is no longer able to distinguish between what is harmful and what is not.  The ethics put forth by the Hippocratic Oath demand nothing less.